Nissen Fundoplication and G-Tube for SMA

Overview
Nissen fundoplication (NF) is a surgical procedure that involves wrapping the stomach around itself to prevent acid reflux. “Wrapping” tightens the sphincter muscle between the stomach and esophagus, making it more difficult for food to back up into the windpipe. The procedure may be recommended when people with SMA have severe reflux and are aspirating (inhaling) stomach acids into the lungs, putting them at risk for serious breathing problems including aspiration pneumonia.

Reflux is most common in children with SMA type 1 and occasionally in SMA type 2. Reflux may cause frequent upper respiratory infections, poor weight gain, and pain or vomiting when lying down. Severe reflux may even slow growth. When reflux medicine fails to control the problem, NF surgery may be recommended.

For those who cannot eat by mouth, a gastrostomy (G-tube) may also be needed with NF surgery. Newer laproscopic procedures allow NF and G-tube surgery to occur at the same time, reducing recovery time.

Nissen fundoplication can have serious long-term complications, including recurrence of reflux. NF is not fully reversible. People with SMA and their families are encouraged to discuss all options with their doctors – including alternate types of fundoplication surgeries and feeding tubes – before making a decision.

What does it involve?
Prior to surgery, the doctor will conduct tests to measure frequency and severity of reflux.

During NF surgery, the top of the stomach (also known as the fundus) is wrapped completely around the bottom of the esophagus and stitched in place. The wrap acts as a one-way valve, allowing food into the stomach and out of the esophagus. The NF may also temporarily prevent burping or vomiting that can worsen reflux.

NF surgery is often performed using minimally invasive laparoscopic or endoscopic procedures.

Typical hospital stay is one or two days after surgery.

Intended Outcome
Nissen fundoplication combined with a G-tube is intended to prevent reflux.

Results
A 2013 observational study of 4,163 infants was inconclusive in determining the effectiveness of NF and G-tube surgery in reducing reflux-related hospitalizations. An earlier review of NF and G-tube surgery concluded that laparoscopic NF surgery can be performed safely, but recurrence was a long-term risk.

Positive long-term outcomes among children who’ve had NF surgery include improved quality of sleep, fewer respiratory symptoms, and overall improved pulmonary functioning. In cases where NF surgery can save a life, benefits may outweigh risks.

More research is needed to determine short and long-term outcomes of fundoplication surgery in people with SMA and reflux.

Constraints
Any surgery carries risks including blood clots, blood loss, infection, breathing problems, reactions to medication, and heart attack or stroke during the surgery. Postoperative complications of combined NF and G-tube surgeries include wound infection, wound rupture, and pneumonia, similar to complications of other abdominal surgeries.

Common side effects of NF surgery include gas and bloating, ongoing reflux or vomiting, difficulty swallowing, dumping syndrome (when food travels too fast from stomach to intestines), abdominal pain, nerve damage and sensitivity, delayed stomach emptying, and motility problems.

Children with SMA tend to fare worse with NF surgery, which has a higher risk of complications than other fundoplication techniques (involving partial stomach wraps). The rate of recurrence – and need for repeated surgical interventions – with NF surgery ranged from 4 to 22 percent.

For more details, visit:
1. Fundoplication & Pyloroplasty – Feeding Tube Awareness Foundation
2. Guide to Gastrostomy Tubes – Rady Children’s Hospital San Diego
3. Nutrition Basics – Cure SMA
4. Fundoplication & Pyloroplasty - Feeding Tube Awareness Foundation
5. Gastrointestinal tract feeding access and the role of fundoplication in combination with gastrostomy ー Current Opinion in Pediatrics
6. Effectiveness of Fundoplication at the Time of Gastrostomy in Infants With Neurological Impairment ーJAMA Pediatrics
7. Nissen vs. Toupet Fundoplication 一 Continuing Nursing Education